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1 Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA (925) Professional Policies and Consent to Treatment Welcome to my practice. I appreciate your giving me the opportunity to be of help to you. This document describes my professional services and policies. As a client in psychotherapy, you have certain rights that are important for you to know about. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you. It is important to me that you know how we will work together. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do. By signing this form, you are acknowledging and agreeing to these policies. My Professional Background I received my doctorate in Clinical Psychology from Michigan State University, which is accredited by the American Psychological Association (APA). My professional training in graduate school involved training in research, teaching, and clinical assessment and therapy work with all age groups. I completed my clinical internship at the University of Southern California Keck School of Medicine / Childrens Hospital Los Angeles, which was an APA accredited internship training site. My specialization during internship was in general child mental health and pediatric psychology. Following, I completed a clinical postdoctoral training year at Seattle Children s Hospital, focusing on severe mental illness in children and adolescents. I then completed a fellowship in interdisciplinary assessment of neurodevelopmental disorders at the University of Washington Medical Center s Center on Human Development and Disability. I have also completed programs in Leadership and Education in Neurodevelopmental Disabilities through Childrens Hospital Los Angeles and the University of Washington which provided me with specialized training in interdisciplinary collaboration in the treatment and identification neurodevleopmental disabilities. In 2010, I received my psychologist s license from the State of Washington. In 2011, I moved to California and received my psychologist license in California (lic.#psy24097). Psychological Services As a clinical psychologist, I provide therapy, assessment, and testing for individuals of all ages. My theoretical orientation is integrative and grounded in evidence-based practices in psychology as recommended by the American Psychological Association. This means that my approach is informed by the best research evidence on treatment and assessment techniques that work while taking into account each individual client s characteristics, goals, and cultural background. I draw from cognitive behavioral ( CBT ), psychodynamic, interpersonal, mindfulness, and dialectical behavioral theories in my therapeutic work with clients. I typically use the first few sessions with a client as an evaluation period, providing you an opportunity to get a feel for me and reflect on whether or not I will be a good match for you. I use this time to get a chance to know a client and their treatment needs. I will also discuss with you my approach to psychotherapy, as well as risks, benefits, and other important aspects. I may also recommend psychological testing or other forms of assessment. After the initial evaluation phase, we will discuss a treatment plan. I view therapy as a partnership between us. You define the problem areas to be worked on; I use my training and experience to help you make the changes you want to make. Success requires that you work in session as well as outside of sessions as appropriate. For child clients, this often means that children and Page 1 of 6

2 their parents will need to modify their behavior in order to help the child client. The Benefits and Risks of Therapy As with any powerful treatment, engaging in therapy involves some risks. It is worth considering both the benefits and the risks when deciding whether to begin treatment. For example, in therapy, there is a risk that approaching feelings or thoughts that you have tried not to think about for a long time may elicit strong negative feelings like sadness, guilt, anxiety, anger, or loneliness. Making changes in your beliefs or behaviors can be frightening or uncomfortable, and sometimes disruptive to the relationships you already have. You may find your problems temporarily worsen during the beginning of treatment. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. Most of these risks are to be expected when people are making important changes in their lives. While you consider these risks, you should also know that many people find therapy very beneficial and research into whether therapy works shows that it generally works very well. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out until their feelings are relieved or the problems are solved. Clients relationships, capacity for coping with adversity, and emotional vitality may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions as individuals, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. Sessions and Policy for Missed Appointments My practice operates by appointment only. Each session is typically scheduled for 50-minutes; however, there are times where I may schedule longer sessions. If, after the initial evaluation, we agree to begin therapy, we will decide on the frequency of meetings (usually once a week) and find a mutually agreeable regular time to meet. If you are unable to keep an appointment, I request that you give me 24-hours notice. Unless the circumstance Page 2 of 6 involves an emergency, I will bill you for appointments you do not cancel within 24-hours of the appointment time. It is important for you to know that insurance companies do not pay for missed appointments. Professional Fees Fees for individual and family therapy for a typical 50-minute session are $ per session. Intake interviews (the initial evaluation session) are 90- minutes long and billed at $ Psychological assessment fees vary according to the type of assessment, materials, and amount of time required. Extended phone calls or excessive regularly occurring phone calls will also be billed at regular rates based on their length. I may periodically increase my fees, but your agreed upon fee with me at the outset of treatment should not be affected. I offer a sliding scale fee system for a limited number of clients with special financial circumstances. Unless by other arrangement or if I am contracted with your insurance company (see next section), the entire therapy session fee is due at the time of service. For psychological assessments, half of the fee is due at the time of the initial meeting and the remainder is due at the time of the feedback meeting. Payments can be in the form of cash or check, made payable to Lisa Tang. A $25.00 fee will be added to your balance for any check returned by the bank. If you are having problems paying my fees, let me know and we can try to work out a payment plan. If you do not pay your debt (over 90-days delinquent), I reserve the right to give your name and the amount due to a collection agency. Insurance If you have insurance with a company that I am contracted with and would like to use your insurance to pay for my services, I will collect your co-payment and bill your insurance with your written permission. If your insurance fails to pay for my services, you are ultimately responsible for the bill. If I do not have a contract with your insurance provider, your plan may cover a portion of my fee as an out-of-network provider. I will provide you with a receipt and information that you can give your insurance company to apply for

3 reimbursement. Behavioral health and testing reimbursement rates vary widely across insurance companies (many insurance companies do not reimburse for psychological assessments / testing). Please contact your insurance company to clarify your coverage options. You are ultimately responsible for the payment of my fees, not your insurance company. If you choose to use your insurance to pay for my services, you should be aware that the insurance company may require certain information about you and our work together. This typically includes your diagnosis and the dates that we meet, but sometimes also includes your symptoms, treatment plan, and prognosis. I will do my best to provide the minimum necessary information to them, but you should know that there are in effect no restrictions on what they may request. Insurance companies also often require that clients have certain diagnoses in order to authorize treatment and the authorization process can take up to 6 weeks for some companies and there is no guarantee that initial authorizations will remain effective. You should also know that your insurance company will retain the information that I give you as part of your medical information record. Any time you sign a blanket release for medical records from your insurance company, information from our treatment may be released along you re your other medical records. This is particularly a concern when you are applying for a job, life insurance, or other health insurance. Legal Proceedings If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. You may become involved in other court actions such as litigation that requires my participation. It is important that you know that you will be responsible Page 3 of 6 for payment for any professional time required (e.g., phone calls, transportation, time in court, time meeting with your or the other party s lawyers) even if I am compelled to testify by another party. Due to the complexity and difficulty of legal involvement, I charge $250 an hour for preparation and attendance at any legal proceeding. I am an independent practitioner. Although I share office space with other psychologists, we are not a group and we do not function as a group; I am not liable for the actions of any other provider in the building and they are not liable for any of my actions. What to Expect from Our Relationship The relationship between client and psychologist is unique because it is designed to help the client increase their well-being. The relationship can become emotionally intense which increases its capacity to heal but also requires certain constraints to protect the client s well-being. Towards this end I follow the ethical standards of the American Psychological Association (APA). Let me explain these limits, so you will not think they are personal responses to you. First, I am licensed and trained to practice psychology not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints. Second, state law and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited situations (explained in the next section). If I see you on the street or socially, I may not say hello or talk to you very much. This is not a personal reaction to you, but rather a way to maintain the confidentially of our relationship. Third, in your best interest, and following the APA s standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a

4 business relationship with any of my clients, other than the therapy relationship. Even though you might invite me, I will not attend your family gatherings, such as parties or weddings. Confidentiality With certain special exceptions described below, you have the absolute right to confidentiality of your therapy. I cannot and will not tell anyone else what you have told me without your prior written consent to do so. The following are legal exceptions to your right to confidentiality. With few exceptions, I will inform you when I think I will have to put these into effect. If you become unable to care for yourself or threaten dangerous action or serious bodily harm to yourself, I may need to release information about you to keep you safe, including referring you for hospitalization. If I have good reason to believe that you are abusing or neglecting a child, elderly person, or vulnerable adult, or if you give me information about someone else who is doing this, I am required by law to immediately inform the Department of Child and Family Services or Adult Protective Services of this concern. If you tell me that you intend to seriously harm another person, I am required by law to warn that person of your intentions and to contact police and ask them to protect your intended victim. If I receive a request or subpoena to release records for a legal proceeding about our treatment, I will assert privilege (the right to refuse to disclose our confidential communications) on your behalf unless you or your legal representative give me written consent to do otherwise. You should know, however, that the court may require me to release this information, in which case I may have to do so. If you are involved in a legal proceeding where you raise the issue of your mental or emotional health, there will be no privilege. Please consult your lawyer about these issues. There are two other situations in which I might talk about part of your case with another therapist: First, in order to provide you with the best possible service, I may consult with other Page 4 of 6 therapists or other professionals. I will not give them your name and they would only be told the minimum amount of information needed for them to understand your situation and provide me with consultation. These other therapists are also required to keep your information private. Second, when I am away from the office on extended absences, I may arrange for a trusted therapist to cover for me. This therapist would be available to you in cases of emergency while I am away. Therefore, he or she would need to know about you. Of course, this therapist would also be bound to the same laws of confidentiality that I am. Please read my Privacy Policy for further information about how I use or disclose protected health information. If You Need to Contact Me I cannot promise that I will be available at all times. For example, I do not take phone calls when I am with another client, outside of business hours, or when I am on vacation. You can always leave a message on my confidential voic and I will generally return your call within a business day as long as I am not on vacation. Please know that when you or I use a cell phone it may not be secure. You can also contact me about appointment scheduling via at I do not communicate about personal/clinical issues via for two reasons. is not entirely confidential as system administrators and others may potentially be able to access our messages to each other. Secondly communication via is vulnerable to misinterpretation as there are no clues as to what someone is feeling, to the emotional context of their message. Crisis or Emergencies I do not carry or pager or subscribe to an answering service. In the event of a crisis, you can call the 24-Hour Alameda County Crisis Line at or dial 911. If you believe that you cannot keep yourself safe, please go to the nearest hospital emergency room and ask for the psychiatrist on call. The emergency

5 room physician should be given a release to speak with me. Complaint Procedures It is my intention to fully abide by all the rules of the American Psychological Association(APA) and by those of my state license. Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if your concerns with me are not worked out. I will take such criticism seriously, and with care and respect, and I will make every effort to seek solutions to them. If you feel that I (or any other psychologist) have treated you unfairly or have even broken a professional rule, please tell me. You can also contact the California Department of Consumer Affairs if you have questions or complaints regarding the practice of psychology. Page 5 of 6

6 Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA (925) Agreement for Individual Therapy I,, the client, agree to receive psychotherapy treatment with Dr. Tang. I take responsibility for the payment of Dr. Tang s fees for these services at a rate of $ for intake sessions and $ per 50-minute therapy session. be billed at an hourly rate to my insurance company. I understand that I will be responsible for any co-pay and any remaining balance that my insurance company will not pay. I have also reviewed and agree to Dr. Tang s policies regarding missed appointments and understand that Dr. Tang reserves the right to provide my name to a collection agency should I become delinquent in paying for services rendered (90-Days post-due unless by other arrangement with Dr. Tang). If I choose to use my insurance to pay for Dr. Tang s services, understand that there is no guarantee that my insurance company will make payment and that I am ultimately responsible for any financial obligation to Dr. Tang. I have read or received the above written professional policies regarding my rights regarding treatment, the qualifications of my provider, confidentiality in treatment, grievance procedures, and crisis/emergency procedures. I understand that under state and federal law, Dr. Tang is required to make exception to confidentiality when she suspects that child, elder, or vulnerable adult abuse is occurring, if I become a danger to myself, if I threaten serious bodily harm to someone else, or when there is a court order compelling Dr. Tang to release confidential patient information. I understand and consent to Dr. Tang consulting with other therapists and to arrange for professional coverage when she is on vacation. I understand that there are no specific promises made by Dr. Tang about the results of treatment, the number of sessions necessary for therapy to be effective, or the effectiveness of the procedures used by Dr. Tang. I am voluntarily consenting to my treatment with Dr. Tang and understand that I may withdraw this consent at any time for any reason. Signature of Client Date I, the therapist, have discussed the issues above with the client. My observations of this person s behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent to his / her own treatment. Signature of Therapist Date Copy accepted by client Copy kept by therapist Page 6 of 6

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